Psychological Services In the public domain

2015, Vol. 12, No. 3, 303–312 http://dx.doi.org/10.1037/ser0000028

Effect of Mindfulness on Vocational Rehabilitation Outcomes

in Stable Phase Schizophrenia

Louanne W. Davis and Paul H. Lysaker Jean L. Kristeller

Richard L. Roudebush VA Medical Center, Indianapolis, Indiana State University
Indiana and Indiana University School of Medicine

Michelle P. Salyers Amanda C. Kovach

Indiana University Purdue University Indianapolis and ACT Richard L. Roudebush VA Medical Center,
Center of Indiana, Indianapolis, Indiana Indianapolis, Indiana

Shannon Woller
Richard L. Roudebush VA Medical Center, Indianapolis,
Indiana and Indiana University School of Medicine

This report describes the results of a randomized controlled feasibility study of the Mindfulness
Intervention for Rehabilitation and Recovery in Schizophrenia (MIRRORS). MIRRORS is an adaptation
of Mindfulness-Based Stress Reduction designed to help persons with schizophrenia to persist and
perform better at work. Thirty-four participants with schizophrenia or schizoaffective disorder who were
engaged in outpatient services were enrolled in a vocational rehabilitation program that included a job
placement and then were randomized to receive MIRRORS (n ⫽ 18) or Intensive Support (n ⫽ 16) over
a period of 16 weeks. The number of hours worked was recorded weekly and job performance was
assessed monthly using the Work Behavior Inventory. Results of t-tests revealed that participants in the
MIRRORS group worked a significantly greater number of hours and performed significantly better at
the end of the 4-month intervention than those in the Intensive Support condition. Repeated-measures
analysis of variance revealed that the MIRRORS group worked more hours each week on average and
that this difference increased over time as well as having generally better work performance compared
with the Intensive Support group. Results suggest a link between MIRRORS and higher levels of work
performance and persistence in people with schizophrenia. Further research is indicated to evaluate
MIRRORS in a fully powered randomized controlled trial.

Keywords: schizophrenia, mindfulness, MBSR, vocational rehabilitation, work

Many who have schizophrenia wish to work but fail to persist
despite state-of-the art vocational interventions. Several reasons
contribute to a lack of work persistence, among which are impaired
cognition and coping (Bell, Kaplan, & Bryson, 1997; Bebout &
Harris, 1995; Bond, Drake, Mueser, & Becker, 1997; Lysaker,
Bond, Davis, Bryson, & Bell, 2005; McGilloway & Donnelly,
2000; Roe, 2001; Young & Ensing, 1999). For example, people
who have schizophrenia struggle to decipher the behavior of others
and, unable to evaluate the accuracy of their perceptions, they may
assume the worst (Bellack, Blanchard, Mueser, & Sayers, 1993;
Lancaster, Evans, Bond, & Lysaker, 2003; Lysaker, Davis, &
Beattie, 2006). Fueled by distressing thoughts and emotions that
they may be unaware of until too late, persons react by either
escaping from or ignoring such stressors or expressing their dis-
comfort in ways that are ineffective or destructive (Lysaker,
Bryson, Marks, Greig, & Bell, 2004). These dysfunctional patterns

This article was published Online First May 4, 2015.
Louanne W. Davis and Paul H. Lysaker, Department of Psychiatry,
Richard L. Roudebush VA Medical Center, Indianapolis, Indiana and
Department of Psychiatry, Indiana University School of Medicine; Jean L.
Kristeller, Department of Psychology, Indiana State University; Michelle
P. Salyers, Department of Psychology, Indiana University Purdue Univer-
sity Indianapolis and ACT Center of Indiana, Indianapolis, Indiana;
Amanda C. Kovach, Department of Psychiatry, Richard L. Roudebush VA
Medical Center; Shannon Woller, Department of Psychiatry, Richard L.
Roudebush VA Medical Center and Department of Psychiatry, Indiana
University School of Medicine.
This study was funded in part by the Department of Veteran Affairs,
Rehabilitation, Research, and Development Service.
The authors thank the following individuals who contributed to assessments and
fidelity monitoring and assisted with the study intervention: Jessica Allinger, Amy
Strasburger, Nicole Beattie, Sarah Long, Kristen Viverito, Kimberly Wooldridge,
Nicole Mihalek, and Lindsey Henninger. The authors also thank all of the study
participants for their valuable contributions to the study.
Correspondence concerning this article should be addressed to Louanne
W. Davis, Department of Psychiatry, Richard L. Roudebush VA Medical
Center, 1481 West 10th Street 116A, Indianapolis, IN 46202. E-mail:
lwdavis@iupui.edu

303
304 DAVIS ET AL.
interfere with reflecting about and initiating effective problem-
solving (Lysaker et al., 2006) and may result in prematurely giving
up on work.
The Department of Veterans Affairs (VA) provides five Com-
pensated Work Therapy (CWT) programs: Incentive Therapy (IT),
Sheltered Workshop Program (SW), Transitional Work Program
(TW), Supported Employment Program (SE), and Transitional
Residence Program (TR). See Table 4 for a description of these
programs. These programs were designed to provide veterans with
vocational opportunities that promote community reintegration
and enhance functioning (Veterans Health Administration, 2008;
Veterans Health Administration, Information for veterans). Al-
though one of the CWT programs, SE, is the only evidence-based
VA vocational rehabilitation program (Davis et al., 2012), indi-
viduals who have severe and persistent mental illnesses such as
schizophrenia have difficulty engaging and persisting in any vo-
cational rehabilitation program, including SE, for the reasons
mentioned above. O’Connor and colleagues (2011) suggested that
identifying veterans with serious mental illness (SMI) and cogni-
tive impairment and providing them with integrated and adjunct
services might be helpful, and our previous research integrating
cognitive– behavioral therapy (CBT) in TW provided evidence to
support this idea (Lysaker, Davis, Bryson & Bell, 2009). Mind-
fulness is an untapped intervention that might also address barriers
to work persistence, such as impaired cognition and coping when
integrated with vocational rehabilitation services, and it may be
advantageous because it provides a method for accepting (coex-
isting with) thoughts and symptoms with calmness and clarity
rather than needing to change them, as in CBT.
Mindfulness meditation, in the form of Mindfulness-Based
Stress Reduction (MBSR), is a treatment approach that has been
shown to enhance attention, concentration, and emotional self-
regulation in individuals with various chronic mental and physical
health diagnoses (Baer, 2003; Grossman, Niemann, Schmidt, &
Walach, 2004; Hölzel et al., 2011; Kabat-Zinn et al., 1992;
Segal, Williams, & Teasdale, 2002; Teasdale et al., 2000).
Mindfulness is the ability to focus and manage attention with an
open, nonjudgmental awareness of experiences rather than clos-
ing off and avoiding (Davis, Lysaker, Strasburger, Kristeller, &
Brown, 2009; Kabat-Zinn, 2003; Kristeller, 2007). Mindfulness
interventions can teach individuals who have schizophrenia to
notice any thought (pleasant or unpleasant) and choose to allow
the thought to be as it is, rather than “feeding the thought” by
pursuing it or struggling to control it. Individuals ultimately
learn to let the thought go. This is a powerful tool for calming
distressing emotions and physical arousal, allowing individuals
to step back when experiencing dysfunctional thinking, such as
“Everyone thinks I am incompetent, so I will get fired no matter
what I do,” and recognize this as only one thought— one
thought that does not define them and may not necessarily be
accurate. As a result, they can let such thoughts go and get on
with work rather than ruminate and experience crippling emo-
tional distress that may prompt impulsive actions such as quit-
ting work.
Mindfulness interventions appear to be accepted by individuals
who have schizophrenia, who report benefits such as improved
cognition and coping, similar to those with other chronic mental
and physical conditions, (Bach & Hayes, 2002; Brown, Davis,
LaRocco, & Strasburger, 2010; Chadwick, Taylor, & Abba, 2005;
Davis & Kurzban, 2012; Davis et al., 2009, Davis, Strasburger, &
Brown, 2007; Gaudiano & Herbert, 2006; Johnson et al., 2009,
2011; Laithwaite et al., 2009; Lavey et al., 2005; Mayhew &
Gilbert, 2008). Thus far, studies of mindfulness interventions for
schizophrenia have focused on symptom reduction and preventing
rehospitalization. This report presents a randomized controlled
feasibility study of MBSR modified for schizophrenia called MIR-
RORS (Mindfulness Intervention for Rehabilitation and Recovery
in Schizophrenia), which we offered as an adjunct to standard
vocational rehabilitation services. The control condition, Intensive
Support (IS), consisted of a weekly group session with discussion
of work-related issues that facilitated participants to help each
other with problem-solving.
We sought to answer three key questions. First, will MIRRORS
participants experience better work function (work performance
and weekly hours worked) compared with those offered IS? We
predicted that MIRRORS participants would significantly outper-
form IS participants in these areas. Second, is it feasible to deliver
MIRRORS in a VA outpatient clinic setting? We predicted that
MIRRORS could be delivered reliably by trained therapists
(e.g., an average fidelity score of 2.5 on a 0 –3 scale). Lastly, is
MIRRORS acceptable as a treatment to individuals who have
schizophrenia? We predicted that MIRRORS group attendance
would average at least 70% and that participants would indicate
satisfaction with the program as evidenced by their responses to
the Client Satisfaction Questionnaire.
Method
Participants
Thirty-four individuals with a diagnosis of schizophrenia or
schizoaffective disorder confirmed by a Structured Clinical Inter-
view for DSM–IV (SCID: Spitzer, Williams, Gibbon, & First,
1994) were recruited from a VA Psychosocial Rehabilitation and
Recovery Center (PRRC), by clinician, or self-referral. A PRRC is
an outpatient mental health treatment program implemented by a
multidisciplinary team for veterans who suffer from severe and
persistent mental illness and experience significant functional im-
pairment. See Table 1 for demographic characteristics. All were in
a stable phase of illness, defined as having no hospitalizations or
changes in psychotropic medication or housing in the previous
month. Exclusion criteria were active substance abuse or a diag-
nosis of intellectual disability or another neurological disorder
documented in the medical record. Lindenmayer, Grochowski, and
Hyman (1995) published norms of means for Positive and Nega-
tive Syndrome Scale (PANSS: Kay, Fiszbein, & Opler, 1987; Bell,
Lysaker, Beam-Goulet, Milstein, & Lindenmayer, 1994) total and
subscales from a sample of 517 inpatients with a verified diagnosis
of schizophrenia: total M ⫽ 70.2 (12.27), positive M ⫽ 14.05,
negative M ⫽ 19.21, cognitive M ⫽ 14.13, excitement M ⫽ 9.16,
and depression M ⫽ 10.01. On the basis of these norms, our
sample was more symptomatic overall, which appeared to be
driven by higher means on the positive, cognitive, and depression
subscales. Published norms from a sample of 47 outpatients with
a confirmed diagnosis of schizophrenia or schizoaffective disorder,
who were participating in a rehabilitation study (Bryson, Bell,
Lysaker, & Zito, 1997), suggest that our sample performed simi-
larly upon study entry, particularly in terms of total Work Behavior
 EFFECT OF MINDFULNESS ON WORK OUTCOMES 305

Table 1
Demographics and Select Baseline Measures

MIRRORS Support t score or

Demographic (n ⫽ 18) (n ⫽ 16) ␹2 value P
b
Gender 1.00
Male 17 16
Female 1 0
Diagnosis 0.17 .681
Schizophrenia 10 10
Schizoaffective 8 6
Ethnicity 0.39 .533
Caucasian 6 7
African American 12 9
Age, years 53.2 (6.1) 50.1 (10.6) 1.06 .296
Education, years 12.1 (2.7) 12.4 (1.8) ⫺0.49 .630
Lifetime hospitalizations 4.1 (2.6) 4.7 (4.1) ⫺0.49 .625
Age of first hospitalization, years 29.0 (11.7) 30.6 (11.4) ⫺0.37 .714
CAS precontemplation 3.7 (0.8) 3.9 (0.7) ⫺0.89 .383
CAS contemplation 2.4 (0.9) 2.1 (0.6) 0.87 .392
CAS action 4.4 (0.6) 4.2 (0.7) 0.89 .379
CAS maintenance 4.4 (0.4) 4.4 (0.5) ⫺0.15 .886
PANSS total score 77.2 (13.7) 73.2 (14.6) 0.82 .419
PANSS Positive 17.4 (2.8) 15.1 (4.1) 1.94 .061
PANSS Negative 20.1 (5.1) 19.6 (5.4) 0.24 .813
PANSS Cognitive 18.1 (3.7) 18.0 (3.6) 0.09 .931
PANSS Excitement 7.1 (2.8) 7.1 (1.9) ⫺0.08 .934
PANSS Depression 14.6 (5.2) 13.4 (4.4) 0.71 .483
WBI total scorea 3.3 (0.3) 3.0 (0.6) 1.78 .084
WBI Social Skillsa 3.03 (0.5) 2.8 (0.7) 0.86 .396
WBI Cooperativenessa 3.2 (0.3) 3.2 (0.5) 0.31 .758
WBI Work Habitsa 3.8 (0.5) 3.3 (0.8) 2.10 .044ⴱ
WBI Work Qualitya 3.0 (0.4) 2.7 (0.7) 1.60 .121
WBI Personal Presentationa 3.4 (0.4) 3.0 (0.6) 2.18 .037ⴱ
a b
WBI scores are from their initial ratings which occurred during week 2. Fisher’s exact test was used because
the expected frequencies were too small for Pearson ␹2.
ⴱ
p ⱕ .05.

Inventory (WBI: Bryson et al., 1997) score: WBI total M ⫽ 3.2
(SD ⫽ 0.88), social skills M ⫽ 2.74, cooperativeness M ⫽ 3.28,
work habits M ⫽ 2.99, work quality M ⫽ 3.20, and personal
presentation M ⫽ 3.04.
Instruments
The PANSS is a 30-item rating scale with sound psychometric
properties completed by clinically trained research staff following
a chart review and semistructured interview. Items are rated on a
Likert scale ranging from 1 (does not apply) to 7 (extreme). We
used the total score as an indicator of psychiatric symptom sever-
ity. Interrater reliability for this study found good to excellent
intraclass correlations (.81–.97). PANSS raters were not blind to
group assignment.
The WBI assesses work performance for persons with severe
mental illness based on a trained rater’s observation of partic-
ipants at work and an interview with their supervisor. Each of
the 35 WBI items are rated as 1–5 (persistent problem area to
frequent area of strength). The total score is the sum of five
subscales (social skills, cooperativeness, work habits, work
quality, and personal presentation). Data supporting the facto-
rial and concurrent validity of the WBI have been reported
elsewhere (Bryson & Bell, 2003; Bryson et al., 1997). Good to
excellent interrater reliability was found for raters in this study,
with intraclass correlations of .79 –.98. WBI raters were not
blind to group assignment.
The Change Assessment Scale (CAS; McConnaughy, Prochaska,
& Velicer, 1983) is a 32-item questionnaire that asks participants
about their openness to and engagement in the process of
change. Its four subscales correspond theoretically to the four
stages of change: precontemplation, contemplation, action, and
maintenance. Coefficient ␣s for the four scales range from .88
to .89.
The Mindfulness Fidelity Scale (MFS; Segal, Teasdale, Wil-
liams, & Gemar, 2002) is a 16-item treatment adherence measure
adapted for this study from the Mindfulness-Based Cognitive
Therapy–Adherence Rating Scale. Items address the presence or
absence of essential treatment elements, therapist effectiveness,
and perceived receptivity of group members and are rated upon
review of videotaped sessions using a 0 –3 Likert scale (no evi-
dence to definite evidence). Interrater reliability was .78 for two
raters of 10 sessions in common.
The Client Satisfaction Questionnaire (CSQ-8; Larsen, Att-
kisson, Hargreaves, & Nguyen, 1979) is an eight-item treatment
satisfaction measure that uses a 4-point Likert scale (poor, fair,
good, excellent), has excellent internal consistency (coefficient ␣
.87–.93), and good construct and concurrent validity (Nguyen,
Attkisson, & Stegner, 1983).
306 DAVIS ET AL.
Procedure
Data for this study were collected between January 2009 and
September 2010. After institutional review board and VA research
committee approvals, trained study staff explained procedures and
obtained written informed consent from prospective participants.
Upon determining eligibility, baseline assessments were conducted
by either a psychologist or trained research assistant with a bach-
elor’s or master’s degree in psychology. Staff read or explained
items for participants who had difficulty and provided breaks as
needed. Baseline measures were repeated midtreatment (8 weeks),
at treatment end (16 weeks), and at 24 weeks (when the vocational
rehabilitation program ended). The CSQ-8 and a program evalu-
ation interview were additionally completed at treatment end with
a trained member of the study staff who was a doctoral-level
psychology trainee and was not involved in participant assess-
ments or delivery of either intervention. The interviews were
audio-recorded and transcribed verbatim and consisted of seven
questions with suggestions for follow-up probes. Participants re-
ceived a cash payment of $20 for completing each of the four
assessment batteries.
Participants were next enrolled in a vocational rehabilitation
program that was modeled after one of the vocational rehabilita-
tion programs offered at our VA medical center, TW. TW is an
example of one program under the CWT umbrella that is designed
to help participants experience realistic and meaningful vocational
opportunities (see Table 4). More specifically, the vocational re-
habilitation program offered to study participants included a 20-
h/week, $3.63/h job placement at VA medical center work sites
and a monthly meeting with a vocational rehabilitation counselor
that offered vocational assistance, including discussion of super-
visor feedback, troubleshooting work difficulties, and postprogram
planning in addition to referral to the computer laboratory for
assistance with preparing a resume and performing online job
searches. Job duties were equivalent to entry-level positions and
hospital staff provided supervision. Efforts were made to match the
work placements with participants’ interests and skills and in-
cluded escort service (assisting patients in wheelchairs to appoint-
ments), housekeeping (janitorial and laundry work), mail process-
ing, engineering services (grounds and building maintenance), and
information desk (answering phones, greeting, and providing di-
rections). Placements could be terminated for failure to follow
work rules or for substandard performance as determined by the
work site supervisor, although there were no such terminations
over the course of this study. Work performance was evaluated
during the second week of work, at midtreatment (8 weeks), at
treatment end (16 weeks), and at follow-up (24 weeks) by a trained
rater who was not involved in study interventions but was not blind
to study condition. Vocational rehabilitation staff tracked weekly
work hours verified by supervisors and provided participant pay-
ments. Participants were then randomized in blocks of four to
receive either MIRRORS or IS.
MIRRORS is modeled on Kabat-Zinn’s MBSR program, a
standardized eight-session meditation program that has been
taught in clinical and community settings worldwide for over 30
years (Kabat-Zinn, 1992). The overall aim of MBSR is to enhance
participants’ resources for skillfully meeting stressful life circum-
stances. Thus, the weekly MBSR curriculum includes mindfulness
meditation practices; experiential exercises to convey teaching
points; discussion of the experience of meditating; and covering
topics such as the stress response and the effect of meditation in
daily life, in particular for the current study, work. The MIRRORS
manual was initially developed during a previous pilot study
working with individuals who had schizophrenia and significant
anxiety symptoms (see Davis et al., 2007 for details regarding how
MBSR was adapted for individuals who have schizophrenia). The
MIRRORS manual was further developed while working with 14
participants before the randomized controlled pilot study that is the
subject of this report. The resulting MIRRORS manual outlines
group sessions that follow the standard 8-week MBSR curriculum
with an added, explicit emphasis on self-compassion and referring
to work and schizophrenia as a source of stress that participants
have in common during discussions.
Participants gain insight into how to apply mindfulness at work
through their own experience, experiences that others share, and
teacher-guided inquiry rather than being instructed about how to
apply mindfulness to work situations. When participants naturally
brought up stressful work situations that they encountered, they
were prompted to share about ways, if any, that they utilized
mindfulness skills and what they experienced. For example, a
participant might relay that he makes a point to meditate briefly
before he goes to work every day and has noticed that when things
get busy at work he does not get as stressed as he used to and his
boss commented on this change in him. Through class discussion,
participants also learned about how to apply mindfulness skills at
work by hearing other participants share about their experiences
and/or by engaging in discussion about what skills might be
helpful in various work situations. Teacher-guided inquiry en-
hances the learning from experiences that participants share with
the group. For example, a participant may report that when his
supervisor corrects him he notices the thought “my supervisor does
not like me.” The teacher might ask what he noticed at the time in
his body (e.g., neck and shoulders tensing), what he noticed about
what he did or any urges to do something (e.g., stays to himself the
rest of the day, urges to leave and never return), and what he
notices about feelings/emotions (e.g., anger). The teacher may
inquire further about body sensations, which may lead to identi-
fying feelings of embarrassment and disappointment. The teacher
then suggests that the participant become curious about what might
be going on. Is this is a common pattern? If so, what is the usual
outcome/how does the experience tie into what the participant has
learned about stress and coping with stress in class (e.g., didactics
about the effects of stress and perception)? How else he might
utilize mindfulness skills in this situation (e.g., letting go of urges
to react in usual ways or “urge surfing”; treating himself with
kindness and patience)? Awareness of all aspects of the direct
experience at work opens the way for new understanding and new
ways of being with difficult experiences both internal (painful
emotions) and external (interacting with supervisor).
To provide a group experience conducive to participation, group
size was limited to 8 participants, unlike typical MBSR classes that
can range up to 30 participants. Most group sessions consisted of
three to four participants. Instead of the usual 2- to 2.5-h weekly
MBSR class, MIRRORS offered twice-weekly 75-min group ses-
sions to reduce the likelihood of cognitive fatigue. To be consistent
with the open nature of the Vocational Rehabilitation program and
prevent dropouts due to wait time, MIRRORS and IS were con-
ducted as open groups operating continuously; that is, once an
 EFFECT OF MINDFULNESS ON WORK OUTCOMES 307

8-week cycle of MIRRORS ended, another cycle immediately
began. Therefore, participants attended two cycles of MIRRORS
during the 16-week study intervention. To ease difficulties asso-
ciated with program entry weeks, all MIRRORS participants at-
tended a 1-h orientation session. In addition, all MIRRORS par-
ticipants were provided a 15- to 30-min “check-in” with a teacher
during weeks 2, 4, 8, and 16. The check-in followed a standard
agenda that invited participants to discuss successes and chal-
lenges and allowed teachers to further individualize mindfulness
instruction and to assess for any negative effect (e.g., increased
symptoms). MIRRORS participants were given an inexpensive
portable CD player and assigned daily home practice of a guided
meditation recording for 20 –30 min (vs. the 45 min typical for
MBSR), brief informal practice of mindfulness during daily activ-
ities, and observations of specific experiences (e.g., moments
judged to be pleasant and unpleasant). A weekly handout provided
a review of main points from classes, instructions for the home
practice assignment, and tips for home practice. Participants
tracked home practice on a form that they submitted each week. IS
and MIRRORS participants received $5 vouchers redeemable at
the VA store for attending each class.
Classes were taught primarily by the first author, who had a
regular yoga and personal meditation practice for 3 years in
addition to completing an MBSR class and two of three required
trainings for teacher certification by the Center for Mindfulness at
the University of Massachusetts Medical School. She was assisted
by doctoral-level psychology trainees who functioned primarily as
coteachers. The coteachers’ initial training involved completing an
MBSR class and observing/participating during a full cycle of the
8-week MIRRORS intervention. The role of coteacher was intro-
duced and progressively advanced until coteachers were able to
independently conduct the sessions. Ongoing training and super-
vision was provided by the first author and involved maintaining a
personal mindfulness practice, which included attending and/or
leading one to two weekly 30-min mindfulness practices for the
research team and/or medical center staff and participating in
weekly supervision. The primary fidelity assessor was a graduate
psychologist who had a personal mindfulness practice and com-
pleted an MBSR class and one of the three training programs
required for teacher certification by the Center for Mindfulness.
She rated 1 randomly selected group session per month for a total
of 17. Feedback was provided on a timely basis so that the first
author could take corrective action.
The IS control condition involved a weekly up to 90-min group
session that was led by an individual with a bachelor of science
degree in psychology who offered empathic statements and sup-
port and led discussion of work-related issues and concerns, facil-
itating members to support and help one another with problem-
solving. The IS group leader was also available to meet with
participants on an individual basis upon request and was super-
vised by the first author.
Data Analysis
Analyses were performed using SPSS Version 20. Missing data
were interpolated between observations or, when necessary, the
last observation point was carried forward. First, t tests or ␹2 tests
were used to compare MIRRORS and IS participants on demo-
graphic variables, willingness to change (engage in vocational
rehabilitation), and symptoms to determine if randomization pro-
duced equivalent groups. Groups were also compared using t tests
on treatment satisfaction (CSQ-8) and engagement (number of
groups attended) to determine if treatment engagement and cred-
ibility were similar for both conditions. Next, groups were com-
pared on primary outcome measures of quantity of work (total
hours and weeks worked) and quality of work (WBI) at treatment
end. Comparisons of program participation and work quantity and
quality were two-tailed with ␣ selected as .05 despite our having
made directional predictions. Third, repeated-measures analysis of
variance (ANOVA) was performed on weekly hours worked
across 16 weeks and work performance across four time points
(weeks 2, 8, 16, and 24).
Results
A t test comparing groups on demographic variables, baseline
assessments, number of groups attended, and treatment satisfaction
revealed no significant differences, as presented in Tables 1 and 2.
Dropouts were defined as participants who did not complete treat-
ment end assessment, and there was no significant difference in
dropout rate by condition (MIRRORS ⫽ 3 [16.7%]; IS ⫽ 2
[12.5%]; ␹2 [1, n ⫽ 34] ⫽ 0.117, p ⫽ .732). As an evaluation of

Table 2
t Test Results Comparing MIRRORS and IS on Key Outcomes

MIRRORS IS
Measure (n ⫽ 16) (n ⫽ 15) t p Effect size (d)

Weeks of work 15.2 (1.9) 12.8 (4.7) 1.82 .085 0.65

Hours of work 293.5 (40.2) 234.5 (96.1) 2.21 .04 0.76
Treatment end WBI 3.6 (0.4) 3.0 (0.7) 2.44 .023 0.82
WBI Social Skills 3.3 (0.5) 3.0 (0.9) 0.84 .410 0.30
WBI Cooperativeness 3.5 (0.4) 3.2 (0.8) 1.55 .138 0.57
WBI Work Habits 3.9 (0.7) 3.2 (1.2) 1.90 .07 0.70
WBI Work Quality 3.5 (0.5) 2.9 (0.8) 2.43 .021 0.88
WBI Personal Presentation 3.7 (0.5) 3.2 (0.6) 2.20 .036 0.79
Groups attendeda 12.3 (4.4) 10.7 (4.3) 1.05 .302 0.51
CSQ-8 total scoreb 28.2 (2.9) 28.1 (3.2) 0.11 .91 0.04
a
MIRRORS groups attended were divided by two since they were offered twice as many groups as IS.
b
CSQ-8 total score (total points possible ⫽ 32).
308 DAVIS ET AL.
feasibility, fidelity ratings were found to exceed the minimum
standard we set of 2.5, with a mean of 2.62 (SD ⫽ 0.21). In terms
of acceptability, MIRRORS participants attended an average of
77% of group sessions, or 25 of a possible 32 group sessions,
higher than the standard we set of 70%. Participants also endorsed
a high level of satisfaction with the MIRRORS program, as evi-
denced by a total CSQ-8 mean score of 28.2 of 32 possible points
(SD ⫽ 2.9). In addition, home practice logs revealed that
MIRRORS participants reported meditating on average 28.72 min
on an average of 54% of days that they were active in the
intervention and engaging in daily activities mindfully 47% of
days for 27.68 min, all indicative of ongoing engagement in
learning and using mindfulness skills.
Although reporting on all of the qualitative program evaluation
data is outside of the scope of this report, in brief, participants
noted the following about how they used mindfulness skills in the
work context: to let go of uncomfortable feelings (e.g., anger,
depression) and stressful thoughts, to organize thoughts, to stay
present-focused, and to improve openness to and interactions with
others. Participants also indicated that mindfulness helped them
cope both with physical (i.e., pain) and general mental health
symptoms as well as psychotic symptoms, but most often they
mentioned anxiety, stress, anger, impulsivity, and lack of concen-
tration. In addition, when asked if anything about the program
caused participants to feel uncomfortable in any way, all but three
participants responded “no.” Of the three reporting discomfort, one
indicated some discomfort talking with others in the groups set-
ting, one indicated feeling uncomfortable in the group setting
during the first class only, and the third indicated that a meditation
practice called “Mountain Meditation” activated his delusion of
being all-powerful (this had been brought up in class, and it was
recommended that this participant no longer engage in the Moun-
tain Meditation). Participants also indicated they continued to
attend class because they found the material interesting, enjoyed
the group discussions, and wished that the program was longer.
For the analyses addressing our primary hypothesis, three early
dropouts, occurring within the first 4 weeks postenrollment, were
excluded. The resulting sample totaled 31 (16 from the
MIRRORS, 15 from IS). The t tests that evaluated differences in
quantity of work provide full support for our primary hypothesis.
As depicted in Table 2, MIRRORS participants worked more
weeks during the 4-month intervention than IS participants. Al-
though not statistically significant, the effect size was moderate
(d ⫽ 0.65). MIRRORS participants did work significantly more
total hours and performed significantly better at work by the end of
the 4-month intervention compared with IS participants, represent-
ing medium and large effect sizes, respectively (d ⫽ 0.76; d ⫽
0.82). As indicated in Table 3, repeated-measures ANOVA per-
formed on weekly hours worked found significant time, group, and
interaction effects. Depicted in Figure 1, the MIRRORS group
worked more hours on average each week, a difference that in-
creased over time (F(15, 435) ⫽ 2.24; p ⱕ .01). ANOVA results
for work performance (WBI) measured at week 2, midtreatment (2
months), treatment end (4 months), and follow-up (6 months), as
shown in Figure 2, revealed a significant group effect but no
significant time or interaction effect (F(1, 29) ⫽ 6.31, p ⱕ .05;
F(3, 87) ⫽ 2.34, p ⫽ .08; F(3, 87) ⫽ 1.23, p ⫽ .30). Exploratory
analysis of WBI subscales at treatment end revealed that the
MIRRORS group had significantly higher scores on the subscales
of Work Quality (M ⫽ 3.5, SD ⫽ 0.5) and Personal Presentation
(M ⫽ 3.7, SD ⫽ 0.5) than the IS group (M ⫽ 2.9, SD ⫽ 0.8):
t(29) ⫽ 2.43, p ⱕ .05 and (M ⫽ 3.2, SD ⫽ 0.6): t(29) ⫽ 2.20, p ⱕ
.05). See Table 2 for a complete description of these findings.
Discussion
As predicted, participants randomized to receive MIRRORS
sustained work longer and performed better at a time-limited work
placement than those who received a supportive intervention.
Another way to look at this difference in work persistence is that
although attrition occurred in both conditions across the 16-week
program, 78% (14 of 16) of MIRRORS participants remained in
the program for the entire 16 weeks versus 56% (9 of 15) of IS
participants. The significant mean difference in WBI total between
groups (0.60) is clinically significant when considering that those
in the MIRRORS group performed closer to the “4” level, indi-
cating “an occasional area of strength,” whereas those in the IS
group performed closer to the “3,” indicating “average perfor-
mance.” These findings are encouraging and suggest that MIR-
RORS may work synergistically with a vocational rehabilitation
program to enhance work persistence and performance. These
findings, albeit preliminary, raise questions about therapeutic
mechanisms (i.e., how mindfulness helped people achieve better
work outcomes). MIRRORS, an adaptation of MBSR, is designed
to help participants to more clearly perceive life events and be
more aware of patterns of thinking, feeling, and behaving. En-
hanced awareness provides an opportunity to choose to relate to
stressful work and life experiences differently, with less emotional
reactivity, which frees up cognitive resources for more skillful
responding and effective coping. Therefore, mindfulness has the
potential to reduce rumination, self-deprecation, anger, anxiety,
and depression, all known to be symptoms and deficits of persons
who have schizophrenia. Future studies are needed to explore these
outcomes in a larger, more definitive study, as well as possible
mediating variables, such as mindfulness, self-compassion, and
group alliance.
This research produced a treatment manual for MIRRORS and
demonstrated it is feasible to train doctoral-level therapists in
training to deliver with an acceptable level of fidelity. The high-
level session attendance (70%) and satisfaction with MIRRORS
(CSQ-8 M ⫽ 28.2), together with evidence of engagement in home
practice assignments, provide evidence of acceptability. In addi-
tion, the qualitative data indicate that MIRRORS participants
identified benefits similar to those identified by MBSR partici-
pants with other physical and mental challenges. Participants sug-
gested that the intervention be longer. Future research could in-
vestigate more than two repetitions of the MIRRORS curriculum
and/or booster sessions, which may increase the likelihood of
detecting changes in work performance differences over time.
Although we controlled for attention by offering weekly support
groups, future research could control for other features such as
home practice, perhaps matching meditation practice with listening
to relaxing music. In addition, mindfulness studies have consis-
tently revealed a dose response to home practice, which has
resulted recently in investigators using player devices that track
listening time more accurately than concurrent self-report (Car-
mody & Baer, 2008; Wahbeh, Zwickey, & Oken, 2011). Our
participants reported completing at-home practice about half of
 EFFECT OF MINDFULNESS ON WORK OUTCOMES 309

Table 3
ANOVA Comparing MIRRORS and IS on Work Performance and Weekly Hours Worked

MIRRORS IS Group effect Time effect Time ⫻ Group interaction

Measure (n ⫽ 16) (n ⫽ 15) (F) (F) (F)

WBI 6.31ⴱ 2.34 1.23

Baselinea 3.3 (0.4) 3.0 (0.6)
Midtreatment 3.5 (0.5) 3.2 (0.6)
Treatment end 3.6 (0.4) 3.0 (0.7)
6 month 3.6 (0.4) 3.1 (0.7)
Weekly hours 5.11ⴱ 3.62ⴱⴱ 2.24ⴱⴱ
1 18.8 (4.3) 19.2 (3.1)
2 19.9 (0.5) 17.4 (5.6)
3 18.8 (5.0) 16.4 (6.9)
4 18.7 (5.0) 18.6 (3.0)
5 17.7 (6.2) 18.2 (4.0)
6 18.1 (5.2) 16.4 (7.6)
7 18.8 (4.5) 15.8 (7.5)
8 18.7 (5.0) 16.0 (8.3)
9 19.7 (1.0) 12.9 (8.9)
10 17.9 (5.6) 13.7 (9.0)
11 18.1 (5.3) 10.9 (9.7)
12 17.1 (6.2) 11.7 (9.5)
13 18.8 (5.0) 13.3 (9.1)
14 18.8 (5.0) 11.7 (9.2)
15 17.5 (6.8) 10.3 (9.3)
16 16.4 (7.1) 12.0 (10.1)
a
Baseline WBI were conducted during the first 2 weeks of work.
ⴱ
p ⱕ .05 ⴱⴱ p ⱕ .01.

available days for approximately 25 min, but the optimal fre-
quency and duration of at-home practice for this population to
benefit is unknown.
There are several limitations to this study and important con-
siderations for future research. On average, participants were
males in their forties who had been in treatment for many years
and had an overall higher than usual level of symptoms. Thus, it is
unknown how well these findings generalize to women or persons
early in their illness. In addition, participants in this report were
concurrently enrolled in vocational rehabilitation at a VA medical
center, where they were placed in temporary entry-level jobs for
low pay, although assignments were made to reflect participant
interests. Our findings may be generalizable to VA programs that
provide work placements similar to those we utilized. However,
we do not know whether and what modifications are necessary for
applying the MIRRORS program in other vocational settings and
programs, including supported employment. Another limitation
was that our PANSS and WBI raters were not blinded to condition,
which was not feasible because of the small study budget, which
required staff to fulfill multiple roles. Although at this stage of
investigation control groups are frequently waitlist or treatment as
usual, we chose to utilize a condition that controlled for attention.

Table 4
Therapeutic Work-Related Rehabilitation Programs Provided by the VA

Compensated Work
Therapy (CWT) Program
Incentive Therapy program Sheltered Workshop Transitional Work program Supported Employment Transitional Residence
(IT) program (SW) (TW) program (SE) program (TR)

Pre-employment work program Work-hardening program Pre-employment vocational Competitive employment A therapeutic program in
for veterans who have for veterans in a assessment program for program primarily for residential setting for
severe mental illness and/or simulated work veterans who have veterans with serious veterans involved in
physical impairments that environment that pays mental or physical mental illness; consists CWT; participants’
provides a therapeutic wage; on a piece-rate basis; impairments with time- of full- or part-time CWT earnings
may extend for an indefinite average length of stay limited work work with workplace contribute to the cost
period of time (optional is 4–6 months assignments that have accommodations and of their housing and
program). (optional program). the same expectations as therapeutic supports in they are responsible
experienced by non- place until for all aspects of
CWT workers and tax- independent meals (optional
exempt compensation employment is program).
(required program). maintained (required
program).
Note. The mission of the CWT program is to provide realistic and meaningful vocational opportunities to veterans, encouraging successful reintegration
into the community at the veterans’ highest functional level.
310
However, the intensity of the control intervention (up to 90 min/
week) did not match the intensity of the MIRRORS program (90
min/week plus 30-min monthly check-ins with the teacher). Fur-
thermore, the possible effects of MIRRORS participants complet-
ing home practice or the more highly credentialed MIRRORS
interventionists were also not controlled for. The control group for
any future fully powered randomized controlled trial (RCT) should
carefully match the control condition to the MIRRORS program
on all of these factors. In this pilot study, we evaluated outcomes
2 months after the intervention ended, which was also when the
vocational rehabilitation program ended. Future studies should
consider evaluating outcomes over a longer period of time (e.g., 6
months to 1 year after the active intervention is complete) to assess
the enduring benefits of MIRRORS on work and other outcomes.
Because it has been found that benefits of mindfulness interven-
tions are more likely to be maintained when practice is continued,
future studies may wish to evaluate the effectiveness of booster
sessions to promote continued practice.
Conclusions
This pilot project was designed to evaluate feasibility and ac-
ceptability and to serve as an initial evaluation of vocational
outcomes for the MIRRORS intervention. Findings demonstrate
the feasibility of teaching mindfulness interventions with an ac-
ceptable level of fidelity to predominantly male Veterans diag-
nosed with a serious, chronic condition that features distressing
psychotic symptoms. The project has produced a treatment man-
ual, fidelity measure, and therapist training procedures for future
research. CSQ-8 results and preliminary data from program eval-
uation interviews revealed that MIRRORS participants identified
multiple benefits—most importantly, improved ability to deal with
and let go of thoughts and regarding work, improved concentra-
tion, and social skills. Participant feedback indicated that individ-
uals who have schizophrenia are open to a mindfulness-based
intervention. Participants identified benefits similar to what has
been reported in the literature by other MBSR participants expe-
riencing life stressors and coping with chronic physical and mental
health conditions. These data, along with strong session attendance
and home practice adherence, support acceptability. Results from
this study also suggest that a modified MBSR program such as
MIRRORS may help increase the quantity and quality of work in
a population that experiences significant challenges in maintaining
work and interpersonal relationships. We are currently pursuing
funding for a larger, fully powered RCT of MIRRORS to evaluate
efficacy.
MIRRORS = 16
21
Support = 15
19
17
15
13
11
9 in schizophrenia. American Journal of Psychiatric Rehabilitation, 13,
7 224 –242. http://dx.doi.org/10.1080/15487768.2010.501302
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Week
Figure 1. Weekly hours worked over the 16-week intervention for par-
ticipants receiving MIRRORS and IS.
DAVIS ET AL.
MIRRORS = 16
Support = 15
3.7
3.5
3.3
3.1
2.9
2.7
Week 2 Mid-Treatment Treatmend End Follow-Up
Figure 2. Work quality as measured by the WBI for participants receiv-
ing MIRRORS and IS.
Using third-wave cognitive interventions such as mindfulness in
schizophrenia is a relatively new endeavor, and ours is the first
attempt that we are aware of that applies mindfulness specifically
to enhance work outcomes. Investigation beyond an RCT will be
needed to determine which of the MIRRORS program elements
are most important and to determine the ideal length of the inter-
vention. For instance, it is unknown whether participation in the
group sessions without monthly check-ins with teachers is suffi-
cient for improvements in work quantity and quality. Continuing to
investigate ways to improve work functioning for individuals who
have schizophrenia is crucial because inability to sustain work
comes not only at a financial cost to society, but more importantly,
at a significant psychological cost to these individuals, who are
deprived of the opportunity to utilize their intact capabilities and
become increasingly isolated from society.
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Received February 6, 2014
Revision received September 18, 2014
Accepted January 22, 2015 䡲